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2008-2009 Best Practices 2008-2009 Best Practices in Managing Hypertension in Managing Hypertension
Sponsored by AMGA and Daiichi Sankyo.Sponsored by AMGA and Daiichi Sankyo.
Wrap-Up MeetingWrap-Up Meeting November 18-20, 2009 November 18-20, 2009
San Diego, CASan Diego, CA
Henry Ford Health System
Division of Nephrology and Hypertension
An Effective Approach to Lowering Blood Pressure in Chronic Kidney Disease
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Overview
Large urban sub-specialty clinic within the Division of Nephrology and Hypertension
located at a 903-urban academic medical center NP managed CKD clinic
• Upon referral to the clinic many of the patients are considered “resistant”
• 85.4% of patients noted with CKD stages 3 and 4
• Patient characteristics• Older ( mean age = 71)• Predominately AA• Highly complex ( significant co-
morbidities)
Overview
• Real time data submitted into a dedicated queryable CKD database (Web-enabled, FM Pro 8 software)
-matrixed to accommodate multiple CKD variables
-facilitates report generation- ongoing maintenance provided by
systems analyst• Patient data directly submitted into
corporate electronic health record system (Careplus)
Team CompositionTeam Composition
Naima Ogletree, MSN-APN-BC (chair) Schawana Thaxton, MSN, NP-C (co-chair) Jerry Yee, MD (lead physician) Collaborative Relationships
• Pharmacy• Dietitian• Lead CSR• Nursing staff (RN, MA)• IT personnel (software engineer)
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HTN Algorithm
Project Overview
Total engagement of nursing staffImproved design and
implementation of the BP follow up clinic
Develop and distribute BP report card
Project Overview
Applied various modes of delivery of health education information– Shared medical group visits
• Curriculum development (Hypertension and the CKD patient)
• PharmD lecture on medication management– Provision of HTN-specific educational
materials– Increased community awareness via
outreach• BP screening• Educate the community on HTN and its
associated risk in the development of CKD
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Project GoalsProject Goals
Aim 1: determine whether an algorithmic approach to treating HTN could achieve a 60% and 40% attainment rate at a SBP cut point of <140 and <130, respectively
Target achievement rates increased to 65% and 45% for SBP thresholds of<140 and <130 mmHg, respectively
Project Goals
Aim 2: determine whether success of anti-hypertensive treatment achieved ANPs using an algorithmic anti-hypertensive treatment strategy equaled that of nephrologists who treated HTN in non-protocolized fashion
NP vs MD Data
Data
Period
05/09 – 07/09
No. Patients
(N)
Mean SBP
(mmHg)
Patients who
Achieved SBP <130
(N)
Patients who
Achieved BP target
(%)
NP 229 134 98 43%
MD 49 132 22 45%
NP vs MD Data
No.
Patients
(N)
Mean SBP
(mmHg)
No. Patients w/ SBP <130
(N)
Patients who
Achieved Target
(%)
NP N = 229 134 N = 98 43%
MD N = 49 132 N = 22 45%
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Modifications/EnhancementsModifications/Enhancements
Aggressive BP therapeutic approach High utilization of CCB and anti-RAAS agents
Employed non-pharmacologic strategies in managing HTN
Routine referral to the RD Encouragement of physical activity
Referral to system weight loss programs Distribution of ‘staying active’ educational handouts
Ongoing education Increased percentage of patients who
achieved BP targets Deferred development of educational
resource nook
Goal Attainment
Time IntervalTotal no. of
patientsMean SBP
(mmHg)
Patients who met target SBP < 130
(%)
12/01/08 – 01/31/09 206 135 44%
02/01/09 – 03/31/09 192 134 47%
04/01/09 – 05/31/09 314 131 50%
06/01/09 – 07/31/09 196 131 52%
08/01/09 – 09/30/09 229 134 43%
Discussion
Outcomes• Consistently met the specified BP target of
SBP <130 over three quarters• Last period assumed care of patients followed
by the graduating fellows
• Departmental QA data consistently exceeded specified BP targets throughout collaborative
• Underscores the importance of the accessibility and availability of a BP follow up clinic
Percent of patients reaching SBP Target: SBP < 130
YearQ1
(Jan thru Mar)
(N)
Q2(Apr thru Jun)
(N)
Q3(Jul thru Sept)
(N)
Q4(Oct thru Dec)
(N)
200745%
170
56%
157
48%
263
55%
250
200842%
286
46%
364
42%
330
44%
355
200947%
323
48%
343
50%
375
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Measuring SuccessMeasuring Success
Performed a literature review and compared published data to our patient population
Literature Review
SBP <130
mmHg
BP
<130/80
(%)
Mean SBP
(mmHg)
J Hypertens 24:395-402
N = 2501 24% 17% 141 ± 20
AJKD 46:18-25
N =186 21% 136 ± 18
Kidney Int 69:538-545;
N = 1058 21% 12%
Hypertens 45:1119-1124
N = 3213 37%
Am J Med 121: 332-340;
N = 10,813 13.2%
NDT 1-6
N = 113 137 ± 15
Results
HFHSPatients who
Achieved
BP <130/80
(%)
Mean SBP
(mmHg)
Patients who Achieved
SBP <130
(%)
12/01/08 – 01/31/09 39% 135 44%
02/01/09 – 03/31/09 134 47%
04/01/09 – 05/31/09 131 50%
06/01/09 – 07/31/09 131 52%
08/01/09 – 09/30/09 134 43%
Mean SBP Data
YearQ1
(Jan – Mar)
Q2
(Apr – Jun)
Q3
(Jul – Sept)
Q4
(Oct – Dec)
2007133mmHg
N = 170
130mmHg
N = 157
132mmHg
N = 263
131mmHg
N = 250
2008136mmHg
N = 286
133mmHg
N = 364
134mmHg
N = 330
134mmHg
N = 355
2009133mmHg
N = 323
132mmHg
N = 343
130mmHg
N = 375
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Challenges?Challenges?
Underinsured/Uninsured Solutions:
Refer to MSW for temporary medication relief Referral to community assistance programs Prescribe generic medications
Shared group visits Generates low revenue Poor participation
– Invited 60 patients – 36% or 22 said yes– 31% or 7 attended
Solutions: Improve marketing of class throughout clinic Integrate method into standard clinic
schedule
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Celebrating AccomplishmentsCelebrating Accomplishments
Embrace team philosophy Appoint head nurse as liaison Provide feedback of progress during staff
meetings
Recipient, NKFM Champion of Hope award that acknowledges innovative programs aimed at improving the management of CKD
Display AGMA award in clinic area Acknowledgement in organization newsletter
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Future StepsFuture Steps
Continue aggressive BP strategy Expand outreach opportunities
Continued community screening and health counseling
Partner with HMO Ongoing collaboration with IM / FP Improve awareness among highest
risk patients
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Lessons LearnedLessons Learned
Development and adherence to BP protocol Use holistic approach
Consider co-morbidities Routine CQI
Give providers feedback Improve access for adequate follow-up Engage the patient
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Questions for the Group Questions for the Group
Have any members had experience using direct renin inhibitors (aliskerin) in their management of HTN?